1. What is chronic throat clearing?

Everyone clears their throat at times. People with
'chronic throat clearing' do it all day,
up to several times an hour, and have been doing so for at least 3 months.
Chronic throat clearing is simply the clearing out of mucous,
or perceived mucous, from one's throat. Here 'throat' means
the area behind the tongue down to the vocal cords.

2. How does chronic throat clearing differ
from chronic cough?

I'll first have you demonstrate the answer. Half swallow some mucous, then
clear your throat. Next, give a good, deep cough. The two actions - throat clearing
and cough - are very different. Cough is a loud barking sound,
caused by attempt to forcefully expel something
from your airways; the thing you are trying to expel could be deep down
in your lungs or in your throat area. Either way, the effort requires
taking a moderate or deep breath and forcefully exhaling with a loud, sharp sound.
Throat clearing is different. It doesn't require taking a moderate or deep breath,
and is more like a heavy, gutteral sneeze. In fact, the chronic throat clearer
often elicits a spontaneous "gesundheit!" or "bless you!" because people think
he's sneezing! That never happens when someone coughs.

Note that, because the problem with throat clearers is mucous in the throat, they
will occasionally feel the need to cough it up as well. However, cough is not
the predominant symptom, throat clearing is. When taking a medical history from
these patients it is important to distinguish between the two symptoms.

Are there other differences between
chronic throat clearing and chronic cough?

Yes, there are other, more profound differences than just the sounds they generate.

1. CAUSE.
Chronic cough is a symptom of some problem that is almost always
identifiable: for example, sinusitis, postnasal drip, asthma, chronic bronchitis,
drug side effect or stomach reflux. By contrast, the cause of
chronic throat clearing is seldom identified (although, like chronic cough,
chronic throat clearing may start after a cold or viral infection).
While there are some specific, identifiable causes of chronic throat clearing,
altogether they are in the minority compared to 'unknown cause'. By contrast,
identifiable causes of chronic cough are far more common than 'unknown'.
Physicians often will presume a cause of chronic throat clearing and
give treatment for that presumption, only to find the patient no better months later.

2. TREATMENT.
Chronic cough is almost always treatable, or
at least suppressable. Depending on the cause, antibiotics, steroids, decongestants,
acid-reflex medication, anti-tussives, etc. may eliminate the cough, or at least
have a definite suppressant effect. By contrast, there is no simple
treatment for most cases of chronic throat clearing; the meds just mentioned
usually have little or no effect.

Is there actually mucous in the throat when
clearing takes place?

Yes, definitely. The mucous is there, and often the chronic throat clearer expels it
into his mouth (where it is swallowed), or if the clearing is especially vigorous,
into the air. The mucous is whitish or slightly yellowish, and is not infected nor bloody; it
is in fact normal mucous that everyone has in their airways. The chronic
throat clearer produces more mucous than is normal and/or feels the
mucous more keenly in his throat than is normal, and thus has an uncontrolled urge
to clear it.

What are some of the presumptive diagnoses
made for chronic throat clearing, and their treatment?

Stomach or GI physicians generally use the term GERD when they attribute
airway symptoms (cough, throat clearing) to acid reflux, whereas ENT (ear, nose, throat)
physicians use the term LPR. Some ENT physicians and speech therapists like to point
out that
GERD and LPR are actually different conditions, but the terms are used interchangeably
by most professionals; in this context, either term means
"your airway problem is from acid reflux." (It's difficult enough for doctors to
make either either diagnosis with certainty, let alone differentiate between the two.)
Treatment for either condition is usually with a medication called 'proton pump inhibitor',
of which there are several (Nexium, Protonix, Aciphex and Prevacid).
Typically prescribed for GERD or LPR, for example, would be Nexium at 40 mg (standard dose)
or 80 mg (double standard dose) a day, plus elevation of the head of the bed while sleeping,
and cessation of coffee or other acid-stimulating foods. If the throat clearing
goes away, the diagnosis is presumed acid reflux from the stomach.
There are no studies on this treatment for throat clearing, and anecdotally it is
rarely effective.

Sinusitis or rhinitis (inflammation of the sinuses and nose, respectively):
Standard treatment includes some combination of antibiotics,
nasal steroids, prednisone and decongestants. If the throat clearing goes away,
this diagnosis is presumed correct. As with acid-reflux, there are no
studies on this treatment regimen in chronic throat clearers, and anecdotally at least,
it is rarely effective.

Asthma. There is actually a report about
asthma causing throat clearing in children (NEJM 2003;348:1502-1503),
with the symptom going away after treatment with steroid inhaler. There
is no comparable report in adults, and I have personally never seen a case
of asthma presenting as undiagnosed throat clearing. Standard treatment for
asthma includes some combination of inhaled bronchodilators, inhaled steroids
and prednisone. Again, there are no studies about this treatment in adult
chronic throat clearers, and anecdotally it is not effective.

Allergies. Here is a patient's comment posted on the web site
Wrong Diagnosis:. "I have gone to several doctors for this
[chronic throat clearing], including an ENT and none of them can tell
me what's wrong. They all just tell me it's allergies and give me
a nasal allergy medicine (which makes it worse)." Allergies is
not so much a diagnosis as a cause for something else,
such as rhinitis (inflammation of nasal passages) or asthma. While allergy
can lead to airway problems, there is no evidence for an allergic cause of
chronic throat clearing, either directly (acting only on the throat) or indirectly (from
rhinitis or asthma).

Does chronic throat clearing occur during sleep?

Most chronic throat clearers seem able to sleep through the night.
Some sufferers will occasionally awake with the need to throat clear,
but nocturnal symptoms are much less common than when awake.
Ability to sleep through the night could be due to
two very different reasons: either the upper airway mucous production is
much less when we sleep (which it is) or the patient is in effect unconscious
and just doesn't feel the acute need to clear as when awake.

Is the problem worse after eating?

For many chronic throat clearers the problem is often worse after eating, not
during the meal. Eating generates acid in the stomach and saliva in the mouth --
lots more secretions are present after a meal than before it. Unfortunately,
this observation doesn't translate into proving a cause or finding effective treatment.
Also, while the symptom is often worse after eating, it is still present throughout the
day and when the stomach is empty, including after sleeping thru the night.

What tests are done to look for a cause?

If a patient with chronic throat clearing seeks professionial help, he or she will
likely undergo a series of tests to find the cause. The tests are divided into whether
the presumed cause is in the airway (nose, sinuses, throat, lungs) or in the gastrointestinal
tract (esophagus, stomach). Tests can escalate and at some point
involve specialists and procedures done under sedation. In large part the extent of
testing depends on the severity of the patient's complaints. A casual complaint of
"sometimes I clear my throat" may not lead to much investigation, whereas "I am constantly
clearing my throat and can't sit in meetings without choking" may lead to the full
monty workup.

AIRWAY-ORIENTED TESTS MAY INCLUDE:

Chest x-ray

Sinus CT scan

Pulmonary function testing

Allergy testing

Referral to ENT specialist for
laryngoscopy;
this test provides direct visualization
of the throat and vocal cords. Laryngoscopy can detect any anatomic abnormality, as well as
determine if the vocal cords move normally, if acid is scarring the throat area, etc.

At any point along this route the patient may be treated with empiric medications
for a possible airway cause, including: antibiotics, inhaled or nasal steroids, prednisone,
decongestants. As mentioned above, there are no studies about these treatments,
and the meds rarely have effect.

GASTROINTESTINAL-ORIENTED TESTS MAY INCLUDE:

Barium-swallow test (if swallowing difficulty is suspected)

Referral to a GI specialist for upper GI (esophagus and stomach)
endoscopy and stomach
acid-measurement tests

At any point along this route the patient may be treated with empiric medications
for a possible stomach cause (reflux of acid), including: proton pump inhibitor (such as
Nexium or Protonix), elevation of the head of the bed while sleeping, and cessation of
coffee or other acid-stimulating foods. Again, as mentioned above there are no
studies about these treatments and they are rarely effective.

What if all the tests are negative?

For most sufferers who undergo testing, the results are usually negative,
and the empiric treatments offered are not effective. At some point, especially if
the patient is evaluated by an ENT specialist, he or she will likely be
referred to a Speech Therapist.

Why 'Speech Therapy' if the problem
is throat clearing?

It is the belief of many ENT (ear, nose and throat) professionals
that chronic throat clearing is a 'learned habit'. The theory
is that at some point -- possibly during an upper respiratory infection -- the patient
had a lot of mucous that had to cleared, as is common in this situation. However,
at that point the patient became highly sensitized to the 'feeling of mucous in the back
of the throat', and after the infection went away continued to 'clear' the mucous.
Then -- and what follows is essential to this theory -- the very act of
throat clearing creates more mucous, placing the patient in
a viscious cycle. THROAT CLEARING PERPETUATES THE THROAT CLEARING.
In this theory THE PATIENT IS CAUSING THE PROBLEM. Without
the constant throat clearing, which ought to be controlled by the patient, the
problem would eventually go away. Speech therapists are trained to help people overcome
this 'bad habit' of throat clearing, and learn how to control the problem.

What do speech therapists recommend?

At this point (all medical tests negative or inconclusive, and
problem is deemed a self-perpetuating bad habit) the goal is to get the patient
to decrease his/her urge to throat clear. While there is no
scientific basis for these recommendations, speech therapists may attest to
success based on selected clinical experience. Many of these methods are
in the realm of
folk or natural medicine, and include:

sharply sniff and then swallow whenever you get the urge to throat clear

drink warm water with lemon juice and honey whenever you get the urge to throat clear

What works best?

There is actually one published study dealing with the last treatment:
Ice cold carbonated water: a therapy for persistent hyperawareness of
pharyngeal mucus and throat clearing, by Acharya AN, Mirza S,
Jones NS. Journal Laryngology and Otolaryngology. 2007 Apr;121(4):354-7.
Department of Otorhinolaryngology--Head and Neck Surgery,
Queens Medical Centre University Hospital, Nottingham, UK.
This is a non-radomized 'observational' study that found
ice cold carbonated water was helpful in many patients. The study
also discusses the failure of most treatments, and the
abstract is worth quoting:

"Chronic throat clearing or a feeling of 'something' at the
back of the oropharynx or nasopharynx is a common cause
for referral to otorhinolaryngology services.
While treatment of an underlying causative condition
might be expected to improve these symptoms, in many
cases a clear underlying cause is not found. Currently,
there is no recognized treatment which is effective against
these troublesome symptoms. This observational study
investigated the effectiveness of a regime of sipping ice cold
carbonated water to try to break the vicious cycle of throat clearing.
Seventy-two patients with these symptoms who had previously
been advised to use the regime were contacted with a
postal questionnaire. Sixty-three per cent of patients documented
an improvement in their symptom severity score. The most
severely and most frequently affected patients had the greatest benefit.
We conclude that the suggested regime can be effective in
breaking the vicious cycle of persistent throat-clearing."

Are there other studies regarding treatment of
this condition?

There are no similar studies I am aware of that deal with treatment of
chronic throat clearing when the cause is unknown. As the Acharya, et, al, abstract
states, "there is no recognized treatment which is effective..."
It should also be noted that many treatments offered for chronic throat clearing
(including all those by speech therapists) are based on the theory stated
above -- that throat clearing begets more throat
clearing. "Break the vicious cycle" and you solve the problem. However, this approach
is simply inferred and not proven by any means.

It is just as possible that chronic throat clearing is NOT perpetuated by throat clearing. It seems
just as plausible that there is true excessive mucous production from certain upper airway structures
that cannot be controlled by the patient, no matter how hard the act of clearing is contained. If
that is indeed the case then speech-therapy-recommendedations seem foolish, much like blood letting was
in the 18th century -- the wrong treatment based on an unproven theory. True,
methods to treat chronic throat clearing won't kill the patient, as blood
letting often did, but they do indicate that we don't know much about why
some people have this annoying affliction.

What are the long term effects of chronic throat clearing?

The answer in part depends on the underlying cause, if one can be found. Asthma, sinusitis,
and acid reflux can all be harmful in the long run, but each presents such a giant spectrum of
disease (in terms of both symptoms and outcome) that generalities are not helpful. Also, in most cases
these conditions are not the cause. Chronic throat clearing is a symptom of something,
but in the absence of specific disease that something appears more
annoying then serious or life threatening. More studies and long term follow up of patients
are needed about this affliction to give any better answer to the question.

Where can I find more information?

There are several web sites dealing with chronic throat clearing, and some of them
contain personal accounts of this malady:

What do readers of this web site recommend?

I have received several emails, all anecdotal, and have no basis to recommend or refute any of the remedies. A specific treatment that is successful for one individual may not work for another, but at this point there is not much more to offer than personal anecdotes. My observations on all these personal accounts:

First, some of the complaints intermingle symptoms of chronic throat
clearing with chronic cough. As pointed out above,
many sufferers do cough on occasion (because of volume or location
of mucous in their throat), but the main symptom is the constant
throat clearing and not chronic cough.

Second, many of the patients have been diagnosed with presumed causes,
treatment for which is seldom effective. Presumed causes, discussed in
more detail in the above web sites, include "laryngopharyngeal reflux,"
"gastrointestinal reflux disease (GERD)," "allergies," "post-nasal dripping"
and "sinusitis."

Third, patients evince some frustration with the
medical system. It is common situation in these accounts that a chronic
throat clearer has seen several doctors (18 mentioned in one email), received a variety of
diagnoses and taken many treatments. One could chalk this up to 'comment
bias', i.e., only those who are frustrated post comments on the internet or bother to email me.
However, frustration seems to be the norm for chronic throat clearers.
The reason is because, in the vast majority of cases, physicians
can't find the cause and there is no proven effective treatment.

Below are two emails that seem particularly interesting.

Adderall and Elavil for CTT?

"My chronic throat clearing problem surfaced when I entered menopause.
I have tried every procedure and med possible - per 18 different doctors and specialists who could find no
cause or relief option. By accident, I found a med that totally and immediately cleared up my throat congestion -
Adderall XR 15. (I was tested at "50" for ADHD and was found to have ADHD w/Anxiety.)
The first day on this med for ADHD, the globus sensation totally disappeared, my lungs felt 20 years younger,
I did not feel like the poster child for cystic fibrosis (a.k.a. Juicy Lucy). I could eat and drink
ANYTHING w/o it affecting me. (Eating and drinking always increased the globus sensation and need to clear throat.)
This lasted for the 4 days I was on this med. Unfortunately, this new med made my libido too high for comfort,
so we stopped that dosage and backed down to 5 mg. The 2nd med that gave me some relief is Elavil
(tricyclic antidepressant). [A] gastroenterologist at USF's Medical Clinic in Tampa, said Elavil (low dose)
has been found to help some people with IBS [irritable bowel syndrome] who couldn't find relief from any other
traditional IBS med. After hearing my story about Adderall and it's relation to my throat clearing,
he suggested I try Elavil. It helped! So, I have been on Adderall XR 15mg during the day and Elavil 50 mg
before bedtime for 2 years now. Both meds worked best when I first tried them. As my body acclimated,
they became less effective, but do still give me some relief. What is their commonality and what are they doing for me?
Both have anticholinergic properties; both raise norepinephrine in the body;
raising norepinephrine levels can help to 'quiet' saliva production, mucus production and
other 'juices' in the body (i.e., digestive). All my bodily juices went on hyper drive when I hit menopause.
Also, I have found that my fluid production increases with stress.
My need for throat clearing ALWAYS increases when my stress level increases. Stress can deplete norephinephrine." (From email received June 25, 2009)

MucoStop for CTT?

Just read your comments on chronic throat clearing and thought I'd add my story. All my life I've wanted to be an actor and a musician/singer, but my vocal quality and range (mostly the lower range) has been inhibited by thick mucus that forms on my larynx. Occasionally it will go away briefly for no apparent reason, but always comes back. It is not painful or inflamed, just a thick, heavy mucus that layers up and won't go away. I found a product called mucostop by enzymedica that actually produces results. It's an over the counter dietary supplement. I'd say while taking this stuff I am about 90% cleared up. I ran out recently and it came back with a vengeance, so I'm obliged to order some more if I want to be able to talk without clearing my throat. It's rather expensive (about .50 a cap), so I'd still like to find out what is causing the mucus in the first place. If it is something I'm eating or drinking, I could control it through my diet. I was considering talking to a doctor, but your readers' comments as regards the medical profession made me realize the doctors don't know anything, so I am pretty much on my own.If you should find the mucostop helpful, of if you learn of some other approach I might try, let me know. (From email received April 27, 2012)